The management of the patella in total knee arthroplasty (TKA) traditionally has been one of three options: always resurface, never resurface, or selectively resurface the patella. Historically, implant design and surgical technique did not completely address the patellofemoral articulation. Increased understanding of patellofemoral anatomy, biomechanics, implant design, and surgical technique have led to an improvement in the previously reported high rate of patellofemoral complications associated with TKA. Traditional indications for patellar resurfacing, including age, weight, gender, patellar anatomy, quality of articular cartilage, radiographic findings, and the presence of rheumatoid arthritis deformity and preoperative anterior knee pain continue to be debated. Anterior knee pain before and after TKA must not always be presumed to be secondary to a patellofemoral resurfacing/nonresurfacing etiology, and other factors may play a role in the dynamic development of anterior knee pain after TKA. The decision to resurface the patella in TKA remains controversial, and the results of longer-term randomized controlled trials will improve understanding of this complex issue in the future.